Evidence-Based Outcomes

The influence of teamwork culture on physician and nurse resignation rates in hospitals

David C Mohr*†§, James F Burgess Jr*†§ and Gary J Young*†§

*Center for Organization, Leadership and Management Research, VA Boston Healthcare System; †Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA

Employee turnover is a critical concern, particularly for hospitals, because they face a very tight labour market for hiring replacements, and high turnover itself may have substantial negative effects on the continuity and quality of patient care. Hospitals with a stronger teamwork culture may experience lower turnover but this has not been formally studied. Research on determinants of employee turnover has not separated out resignations from the larger, more inclusive definition of turnover that includes retirement. This study investigated the relationship between the teamwork culture of hospitals and physician and nurse resignation rates. The study setting was the Veterans Health Administration (VHA). Each hospital was assessed on teamwork culture based on a survey of current employees. Hospital-level resignation rates were obtained for physicians and nurses. Separate multivariate regression models on physicians and nurses were employed. The models included hospital-level characteristics and labour market variables. Analysis of covariance was also performed to attempt to further reveal effects in high versus low teamwork culture hospitals. Teamwork culture was negatively associated with nurse and physician resignation rates, but was statistically significant in the nurse resignation model only. Additional analyses indicated a 0.47 standard deviation (SD) difference in nurse resignation rates and a 0.40 SD difference in physician resignation rates between hospitals in the top and bottom quartiles of the distribution for teamwork culture. In conclusion, these results suggest that developing and emphasizing a teamwork culture may facilitate greater retention of health-care employees, especially nurses.

Introduction

Employee resignation, sometimes referred to as voluntary turnover, is a major management issue for organizations.1 It is well documented that organizations face both direct and indirect costs from this type of turnover.2 – 4 Direct costs include what an organization has to spend to search for and train new employees. Indirect costs include reductions in pro- ductivity and quality of output that stem from

David C Mohr PhD, Investigator; Research Assistant Professor, James F Burgess Jr PhD, Senior Investigator; Associate Professor, Gary J Young PhD, Associate Director; Chair and Professor, Center for Organization, Leadership and Management Research, VA Boston Healthcare System (152M), 150 So Huntington Ave, Boston, MA 02130; Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA §All authors contributed equally to this work Correspondence to: David C Mohr Email: david.mohr2@va.gov

Health Services Management Research 21: 23 – 31. DOI: 10.1258/hsmr.2007.007011 # 2008 Royal Society of Medicine Press

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protracted job vacancies, diminished staff expertise and other problems associated with turnover.

While employee resignations are a serious concern for most organizations, this type of turnover is particularly problematic for hospi- tals. First, these organizations currently confront a tight labour market for many types of workers, particularly health professionals, in seeking potential replacements. According to a national survey, shortages of more than 10% currently exist for several types of health professionals, including nurses for whom the hospital vacancy rate is estimated to reach 20% by 2020.5,6 Critical shortages also exist in a number of hospital-based physician specialties.7

Accordingly, hospitals are highly vulnerable to employee resignations because departing employees cannot be readily replaced. Second, the consequences of voluntary turnover at hos- pitals may be quite severe. In hospital settings, turnover may translate into higher workload pressures for remaining workers that can threa- ten the quality of patient care. Hospital-based nurses reported that when workload was very high, they were more likely to consider leaving.8 There is also evidence that mortality rates are higher among hospitals where the average nurse workload is also higher.9

Accordingly, for many hospitals, a key chal- lenge is identifying best practices for retaining employees. The goal of the current study is to examine the importance of promoting specific aspects of organizational culture, specifically teamwork culture, as a factor in reducing res- ignation rates of hospital-based employees, specifically physicians and registered nurses. Organizational culture, generally, has been defined as ‘a basic set of assumptions that define for us what we pay attention to, what things mean, and how to react emotionally to what is going on, and what actions to take in various kinds of situations’.10 Teamwork culture is one dimension or attribute of the larger culture of an organization that relates to the degree to which an organization empha- sizes cohesion and morale among its employ- ees.11 Although a strong teamwork culture has been demonstrated to have a positive impact on several indicators of an organization’s per- formance and functioning,12,13 no studies have looked at its impact on specific types of employee turnover. Our study focused on one type of turnover – resignations. Resignation can be defined as an act by which an

employee voluntarily leaves an organization. Turnover can include retirement (e.g. disability retirement, early or voluntary retirement), ter- minations, deaths or other losses (e.g. term or contract appointment expiration), whereas res- ignation is more specific to situations where employees voluntarily leave. While the other categories can account for a substantial number of employee losses, they are likely to be less sensitive to employee attitudes about their work environment.

Teamwork culture and employee resignations

The conceptual foundation for a relationship between teamwork culture and employee res- ignations incorporates several mutually rein- forcing pathways. For instance, a culture that emphasizes cohesion and morale is also likely to foster some degree of loyalty and commit- ment among employees to the organization.14

Such loyalty and commitment can be expected to translate into lower turnover among employees. Additionally, a culture that empha- sizes teamwork may engender a workplace that meets what other studies have documen- ted to be strong emotional needs on the part of employees for collegiality and collaboration.15

While, as previously noted, no studies have looked at teamwork culture and employee res- ignations specifically, prior research has investi- gated the role of team-oriented constructs as predictors of an employee’s intention to leave.16,17 Two such studies have focused on nurses and found that key features of teamwork culture, such as group cohesion, were nega- tively associated with intention to leave. Although intention to leave is an attitude about wanting to leave an organization and thus is distinct conceptually from actually leaving, intention to leave has been shown to be a strong precursor of leaving behaviour.18 – 21 Still, whether and to what degree a teamwork culture factors into the decisions of employees to stay or leave their organization is not known.

This study extends the literature on team- work culture by examining its impact on employee resignations rather than their inten- tion to leave. Additionally, most of the studies looking at teamwork attributes and intention to leave focus on the individual employee as the unit of analysis.22 These studies do not consider the turnover experience of

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organizations relative to teamwork culture. Our research hypothesis was that teamwork culture would be negatively associated with employee resignation rates for both physicians and nurses at the level of the hospital. That is, hospitals with higher levels of teamwork culture will have fewer resignations.

Methods

Setting

This study’s setting is the Veterans Health Administration (VHA), US Department of Veterans Affairs. VHA is one of the largest health-care delivery systems in the USA, with approximately 750,000 inpatient stays and over 46 million outpatient visits a year. Approximately 15,000 physicians and 40,000 nurses are employed by VHA. The hospitals within the system operate within similar finan- cial policies and reimbursement procedures. Physicians and nurses are employed in the VHA system using similar special clinical hiring rules (Title 38, Chapter 74, VS Code), which affect various aspects of their employment.

VHA hires physicians and nurses in one of three ways. These health-care providers can be hired directly, either full time or part time. Second, the hospital can also hire them on a fee basis, to be compensated per operation or procedure. The third way is through a con- tract. Individuals can move back and forth from fee basis to employed status and back and forth from contract to employed status. Approximately three-fourths of physicians are VHA employees, with the rest being fee basis or contract. Almost all nurses are VHA employees. Our study focused only on resig- nations by VHA employees.

Measures and data

Resignation rates

Data on hospital-level resignation rates for fiscal year 2004 (October 2003 – September 2004) were used as the dependent variable in the analysis. We obtained data from the VHA Human Resources Turnover Rate database, which included a resignation rate for both physicians and nurses separately. The resigna- tion rate was measured as the number of employees who actively resigned. This

measure also included counts for employees who were transferred to another Federal agency including other VHA hospitals (less than 0.5% for physicians and nurses). We divided the total number of resignations by the average onboard employee count of phys- icians or nurses employed during the fiscal year. The data excluded medical residents. The measure for nurses included only registered nurses. From a VHA national perspective, physician resignation turnover was 8.9% and total nurse turnover was 7.3%; as measured by the total number of onboard employees for the last day of the fiscal year.

Teamwork culture

We measured teamwork culture by using data from a VHA internal employee survey. The survey consisted of separate modules to assess employee perceptions at three different levels: individual, workgroup and organization. Organizational culture was assessed at the hospital level using a Likert-type instrument modified from an existing culture survey.23

The instrument was developed after extensive work and data collection within a prior pilot study of VHA hospitals. Employees were asked to rate each of the items on a five-point scale ranging from ‘strongly disagree’ to ‘strongly agree’. An example item for team- work culture is: ‘Managers in my facility are warm and caring. They seek to develop employees’ full potential and act as their mentors or guides’. Cronbach’s alpha for the four-item teamwork culture scale was 0.90. The survey questionnaire was distributed to a full census of VHA employees in the spring of 2004. A total of 110,490 (52%) employees, out of 212,877 surveyed, responded. Respondents had the option to reply to the survey using one of three methods: the internet, interactive voice response (IVR) or paper and pencil methods. The majority of the respondents (81%) used the web-based method to respond as compared with IVR (13%) or paper (5%). Statistical tests revealed that there were no sig- nificant differences in scores between using the web-based method in comparison to the other two methods on teamwork culture. The data-set contained a total of 134 hospitals. The average number of respondents per hospi- tal ranged from 87 to 2827, with a mean of 778 respondents. We computed a hospital-level teamwork score for each hospital by averaging

Teamwork culture on physician and nurse resignation rates

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the responses of its employees who responded to the survey.

Hospital and labour market variables

In examining the relationship between team- work culture and employee resignation rates, we also accounted for several hospital and labour market variables that can potentially influence employee turnover. The hospital variables included hospital operating budget in millions of dollars and whether or not the hospital belonged to the Council of Teaching Hospitals, as both of these variables are proxies for resource availability that can factor into employee compensation, benefits and perquisites as well as internal opportu- nities that relate to employee retention.24

Also, for the analysis of physician resignation rates, we accounted for hospital internal workforce conditions that were measured as the number of physician provider full-time equivalent (FTE) per 1000 unique patients and percent of physicians over 40 years of age ( from census survey data). Hospitals with an older workforce may have a more stable workforce because individuals may be settled in their job position and in the community. The analysis for nurse resignation rates also included relevant measures of the hospital’s internal workforce, specifically the number of nurse provider FTE per 1000 unique patients and percent of nurses over 40 years of age.

To account for external labour market forces, which relate to the availability of and compe- tition for job opportunities for nurses and physicians, we used county-level demographic data from the Bureau of Health Professions Area Resource File (ARF). From these data, we constructed measures of patient demand for hospital care and the supply of providers in the local area. Our measures of patient demand consisted of hospital inpatient days and outpatient visits in the local area. Additionally, for the physician model we included the number of active physicians in the area, and for the nurse model we included the number of full-time and part-time nurses in the area. We also took into account the size of the general population at the county level.

We matched the data from the ARF to the hospital based on the VA Planning Systems Support Group assignment of county codes to specific hospital service areas. There are no service areas with more than one VHA

hospital. Thus, the noted measures of hospital labour characteristics pertain to the overall numbers for all counties specific to a hospital.

Data analysis

We used multivariate analyses to test the effect of teamwork culture on hospital-level resigna- tion rates for physicians and nurses. Culture is typically treated as an organization-wide characteristic, so we used the hospital as the level of analysis. In an initial set of analyses, we conducted two multivariate regression models, one for nurses and one for physicians, with teamwork culture entered as the main predictor and hospital-level context variables as covariates. We then re-estimated the regression models after adding covariates to capture external labour market characteristics. In another set of analyses, we divided hospi- tals into multiple cohort groups depending on whether teamwork culture scores were in the top, middle two or bottom quartile groups. We then conducted analysis of covariance (ANCOVA) to test for significant differences among these groupings with respect to both nurse and physician resignation rates. We wanted to examine if threshold effects, points where culture may become more influential, existed on resignation rates. We carried out the statistical analyses using SAS Version 9.1.3.

Results

The average hospital-level resignation rate was 6.44% (SD ¼ 4.09) for physicians and 5.25% (SD ¼ 2.68) for registered nurses. In contrast, the total resignation rate for all VHA employ- ees during the study year was 2.9%. The Shapiro – Wilks test indicated that resignation rates for both physicians and nurses were nor- mally distributed. For nurses, teamwork culture was significantly correlated with hospital-level resignation rates (r ¼ 20.21, P ¼ 0.02). For physicians, the bivariate corre- lation between teamwork culture and hospital- level resignation rates was not significant (r ¼ 0.04, P ¼ 0.63). Table 1 reports the means and standard deviations for measures used in the study for physicians and nurses, respect- ively based upon the regression analyses for hospitals with complete data.

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Table 2 presents estimates from the two multivariate regression models that examine the effect of teamwork culture on hospital- level resignation rates for physicians.

Teamwork culture was not significant in either of the two models. Hospital teaching status turned up as a significant predictor of resigna- tion rates in the hospital-level only model

Table 1 Variables, measures and descriptive statistics for physicians and nurses

Variable name Measure Physician descriptives

Nurse descriptives

Mean SD Mean SD

Hospital characteristics Provider per patients Number of providers FTE per 1000

unique patients 2.12 0.72 6.16 1.76

Hospital budget Operating budget (in million dollars) 195.90 146.50 197.12 146.47 Teaching hospital Percent residency programme (0 = no,

1 = yes) 0.46 0.50 0.47 0.50

Workforce over 40 years

Percent of physicians or registered nurses over 40 years from employee survey

0.81 0.13 0.83 0.06

Environmental characteristics Physician/Registered

nurse supply Number of active physicians in area

(Federal and non-Federal)/number of full-time and part-time nurses

5795 5699 9132 7110

Inpatient days Millions of days in a short-term hospital 1.52 1.26 1.53 1.26 Outpatient visits Millions of outpatient visits in a short-

term hospital 4.50 3.40 4.53 3.50

Population Number of people in market area 2.22 1.75 2.24 1.75 Teamwork culture Culture ratings of physicians or nurses 2.84 0.17 2.84 0.17 Resignation rate Percent of resignations per average onboard

employee 6.44 4.09 5.25 2.68

Table 2 Ordinary least-squares regression predicting physician rates of resignations

Model I, culture and hospital characteristics

Model II, culture, hospi- tal characteristics and labour market

b SE b SE

Intercept 10.89 6.52 7.49 6.73 Hospital characteristics

Teamwork culture 22.52 2.00 21.79 2.05 Physician FTE per 1000 unique patients 0.23 0.63 0.72 0.72 Hospital budget (millions of dollars) 2.12 E – 4 0.20 E – 3 25.87 E – 4 3.0 E – 3 Teaching hospital 2.29� 0.95 2.20 0.98 Percent physicians over 40 years 1.60 2.77 1.82 2.78

Labour market Number of physicians in the area 2.67 E – 4 1.89 E – 4 Inpatient visits (millions of dollars) 1.13 0.92 Outpatient visits (millions of dollars) 0.28 0.26 Population (millions of dollars) 20.52 0.62

R2 0.12 0.15 Adjusted R2 0.08 0.09 Degrees of freedom 5118 9113 F value 3.15� 2.26�

�P , 0.05

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(b ¼ 2.29, P , 0.05); these hospitals had slightly lower resignation rates before account- ing for labour characteristics. Table 3 presents the multivariate regression results for nurses. For nurses, teamwork culture was significantly related to resignation rates in both the hospital characteristics model (b ¼ 22.92, P , 0.05)

and in the labour market model (b ¼ 23.48, P , 0.05). No other variables in the two models were significant predictors of resigna- tion rates.

The results for ANCOVA models for both physicians and nurses are displayed in Figure 1. The ANCOVA models accounted for

Table 3 Ordinary least-squares regression predicting nurse rates of resignations

Model I, culture and hospital characteristics

Model II, culture, hos- pital characteristics and labour market

b SE b SE

Intercept 20.41 5.61 23.83 5.83 Hospital characteristics

Teamwork culture 22.92� 1.40 23.48� 1.45 Registered nurses FTE per 1000 unique patients 20.25 0.16 20.21 0.16 Hospital budget (millions of dollars) 22.34 E – 4 1.82 E – 3 29.71 E – 4 2.22 E – 3 Teaching hospital 0.33 0.60 0.42 0.66 Percent registered nurses over 40 years 25.75 4.03 28.16 4.12

Labour market Number of registered nurses in area 21.76 E – 4 1.63 E – 4 Inpatient visits (millions of dollars) 20.79 0.65 Outpatient visits (millions of dollars) 0.18 0.21 Population (millions of dollars) 0.74 0.43

R2 0.10 0.13 Adjusted R2 0.06 0.07 Degrees of freedom 5117 9112 F value 2.49� 2.24�

�P , 0.05

Figure 1 Results of analysis of covariance for teamwork culture and resignation rates

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the hospital characteristics and labour market characteristics as noted above. The result of the ANCOVA for nurses was statistically sig- nificant, F(10,111) ¼ 2.14, P ¼ 0.02. Specifically, the hospitals in the top quartile of teamwork culture scores had adjusted resignation rates that were 1.30 adjusted percentage points lower, or the equivalent of 0.47 of a standard deviation of the score distribution from the bottom quartile group. The difference between the top quartile and in-between cohort was similar in direction, with a difference of approximately 1.20 adjusted percentage points for resignation rates. The result of the ANCOVA was also significant for physicians, F(10,113) ¼ 2.29, P ¼ 0.02. Resignation rates were lowest in the quartile of hospitals with the highest teamwork culture score (5.41), fol- lowed by the middle cohort (6.58) and the cohort with the lowest teamwork culture score (7.06). The difference between the top and bottom quartile was 1.65 adjusted percentage points lower, or the equivalent of 0.40 stan- dard deviation units.

Discussion

In our study, we found teamwork culture to be significantly and negatively associated with resignation rates for nurses. Although the overall amount of variance explained was rela- tively small in the regression models, an increase of 1 standard deviation unit in team- work culture would equate to having total nurse resignations diminish by 8%. In a hospi- tal with 300 nurses, a change of this magni- tude would translate into 1.25 fewer nurse resignations during a 12-month period. For physicians, the effect of culture was not stat- istically significant in the regression model, although the coefficient was in the same direc- tion as the coefficient in the nurse model. The ANCOVA model for physicians indicated that resignation rate was significantly lower in hos- pitals in the highest quartile of teamwork culture scores. Thus, the results suggested that hospitals with a stronger teamwork culture may have lower rates of resignations for both physicians and nurses once the ANCOVA model is accounted for.

Research suggests that physicians and nurses may view teamwork differently in the same setting.25 – 27 For example, surveys show that the two groups differ on how positively

they rate the strength of teamwork in their own clinical settings, with nurses typically rating teamwork lower than physicians do. These two professional groups may view teamwork differently due to differences in status, clinical arrangements and responsibil- ities, and training.28 For example, nurses who work in the VHA typically do not work outside VHA hospitals, whereas many phys- icians affiliated with the VHA are in fact part-time employees who often spend some percentage of their time in other clinical set- tings. Thus, VHA physicians are more likely than their nurse counterparts to be interacting with a larger and more diverse set of col- leagues. Even within the same hospital, phys- icians usually attend to patients on different inpatient units or outpatient clinics during the course of their workday, whereas nurses tend to work on only one unit or clinic for their entire workday. Accordingly, physicians may view teamwork as a less central feature of their professional lives than nurses do and so their decision to stay or leave the employment of a hospital would be expected to be less sen- sitive to the teamwork culture of the hospital. We did examine this issue in follow-up analy- sis by using only the culture scores of phys- icians and nurses instead of the facility-level culture score. Those results were consistent with the facility-level model.

Several limitations of the study should be noted. First, the study was conducted using data from a single point in time and used a limited number of observations. This limits both the number of predictor variables that can be included in models and the ability to determine if changes in culture affect changes in resignation rates or if resignation rates may influence culture. In fact, some research in the hotel industry has examined the concept of a ‘turnover culture’ as a driving mechanism of resignations.29,30 If turnover rates are low, then it may allow individuals more opportunity to develop a teamwork culture, so there is likely to be strong serial correlation patterns at the facility level.

Follow-up analyses to the study can be done to address these limitations that involve col- lecting organizational culture data and resig- nation rates using multiple years of data and linking teamwork culture as a means for explaining resignation rates. The use of struc- tural equations modelling is one way to increase the effective sample size because

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units measured at multiple times count as multiple observations. This methodology would also allow us to model additional vari- ables that may explain a greater percentage of variance than accounted for in the present study.

Second, because the study setting involves hospitals that provide service to military veter- ans exclusively, the generalizability of the results of this study to other types of hospitals is open to question, although the facility-level resignation rate in this study was comparable to other studies.31 Certainly, VHA may attract health professionals with different goals and values compared with health professionals employed at private-sector hospitals that may influence their inclination or lack thereof to resign. Health professionals working in the VHA also face certain constraints in moving in and out of federal government service due to retirement benefits and other financial con- sideration. A more formal comparison invol- ving retirement plans among Federal and non-Federal hospitals may help to explain reasons for resignations for more tenured employees. Accordingly, research is needed to examine the generalizability of the results we observed in this study.

The study considered only local labour market conditions. This is based on the assumption that individuals choosing to resign from an organization may decide to leave for a different hospital in the same market area, rather than in a completely differ- ent market area of the USA or even abroad. Again, physicians could be expected to have more extra-market mobility, which added to the variation in the physician model that was unexplained. When considering the local labour market variables in the regression model, the parameter estimate of teamwork culture for nurses slightly increased, whereas the estimate for physicians slightly decreased.

Additionally, the study did not identify reasons why nurses or physicians may choose to resign. Data from exit survey interviews could also be useful in examining employee satisfaction and attitudes more directly, as it relates to voluntarily leaving an organization to provide crucial information for managers to act on to reduce dissatisfaction and increase retention. Research has shown that individuals may be more likely to leave organizations for a variety of reasons, such as job stress, lower sat- isfaction,16 organizational commitment and

pay satisfaction.32 We did not specifically address these factors as they have been addressed in other studies, but additional research on factors predicting intention to leave and leaving behaviour may want to con- sider teamwork culture as an explanatory variable.

Finally, an additional direction for future research is to examine the impact of employee resignations on the financial and clinical per- formance measures of hospitals. Although, as noted, employee resignations have direct and indirect costs for hospitals, how resignations affect hospital performance is still not clear and this study hopefully will motivate future research in that area. Indeed, only recently has turnover been examined as a predictor variable of organizational effectiveness. The results suggest that resignations impact effi- ciency in the near term and effectiveness further into the future.33 Thus, the extent to which the resignations of health-care pro- fessionals would impact effectiveness indi- cators such as patient satisfaction and quality of care over the long term is an important topic area for future research.

In conclusion, our results suggest that research on organizational culture is a promis- ing area of inquiry for understanding and reducing employee turnover. We look forward to seeing future contributions to this literature.

Acknowledgements The study was supported by the Department of Veterans Affairs. Technical assistance on obtaining turnover data was provided by Scott Schimetz. The views expressed in this article are those of the authors, and do not necess- arily reflect the position or policy of the Department of Veterans Affairs.

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